Disclaimer: Although the cases I discuss are true, to protect the identity of my patients and myself certain details may be changed. Examples of items that may be changed include a person's gender, age, gravidy and parity, and so on.

Saturday, June 23, 2007

Barrier

I watched some professional fishing on TV the other day. I was working out and there didn't seem to be much else on, so I gave it a try. It's not the kind of sport you would think would lend itself easily to professional competition, let alone compelling TV, but it was actually pretty interesting. The pro fishermen wear shirts loaded with brand name decals, just like race car drivers, and they high five each other when they pull in a big one. I think it's better than actual fishing, because they edit out all the boring parts where you're just sitting around waiting for a fish to bite, and only show the fun parts of reeling in the catch. It's also a lot less slimy on TV than in real life.

This was a redfish tournament, where the fish caught were between about 2 and 6 pounds, weights, I noted, pretty similar to those of the premature babies we take care of. The fishermen got credit for their two biggest fish of the day to be weighed. If they already had two and caught a bigger one, they would throw back a smaller one.

Sometimes we wish we could throw a tiny baby back into the uterus to grow some more, but it obviously doesn't work that way with humans. (That doesn't stop people from joking about it, though. If I had a nickel for every time I heard an obstetrician joke about throwing a tiny one back, I'd be able to retire now.) Occasionally someone talks about a need for an artificial placenta, but nothing has really come of it.

And that might be a good thing. We already struggle with the ethics of taking care of 23 and 24 weekers, babies with mortality and disability rates higher than we would like. What if we had an artificial placenta that we could hook 20 weekers up to? What if we could save some, maybe 20 percent, with a 50 to 75 percent major disability rate in survivors, rates worse than those of our current 23 weekers? Would we be offering that care to parents of such babies? What if some babies at even lower gestations survived, but only a small percent? Where would we stop?

Now, at least, we have a barrier at about 22 to 23 weeks below which no babies survive, because the alveoli - the air sacks in the lungs - are just too far away from the blood vessels that go to the lungs, so carbon dioxide and oxygen can't be exchanged. It's sometimes said that our advances in technology outstrip our advances in ethics (although I don't really think that's true), but hey, it could be worse. Maybe it's good we have the barrier of 22 to 23 weeks - although that's hardly any comfort to the parents of a lost 21 weeker.

What if we had a very good artificial placenta and uterus that allowed 20 weekers to continue to gestate and be born at 40 weeks with a more or less normal prognosis? Or a 10 weeker for that matter? Could bring about a whole different set of ethical questions...

I've never considered it a grand thing that medical science and technology can extend a life beyond it's death, when that death would be timely and good, particularly when it involves someone whose survival would be short term or riddled with complications, pain, suffering, mental disabilities and so on. The age is not a matter for me (22 wks, 22 years, 82 years), nor the reason (premature birth, physical injury, or the ravages of old age). When the quality for a person's life are so low, it is likely the more humane thing to let that person pass, regardless of what we feel about it.

What about liquid ventilation? This seems somewhat promising, though from what I can tell, little practiced now. One of the nurses we met in the ICN had a 24 weeker about 10 or 12 years ago who was ventilated this way, I think at Thomas Jefferson in Philly, and that's probably the only reason the baby (who is now an honor student and doing well otherwise, too) survived. I think that the Japanese and perhaps Scandinavians are still experimenting with this, and I know that I would have liked to have given this a try when we were at a point of respiratory distress with both of our girls last summer.

You know, someone mentioned that when the quality of life is low it is more humane to let them go. Well I don't know how much I agree with that. I have had a couple of doctors say that my sons quality of life isn't there....I disagree. Sure he has CP and is deaf but he is an amazing little guy and perfect the way he is.

I do think it would be interesting if there was a way to have an artificial uterus, but I think that no matter how far medicine comes people will not be happy.

You have the moms now that complain their baby wasn't given the chance at 21 weeks. You would have them complaining then at 19 weeks (if the limit was 20).

Shannon said:I do think it would be interesting if there was a way to have an artificial uterus, but I think that no matter how far medicine comes people will not be happy.

Yes - that would be a brave and wonderful world indeed - lets just get these women out of the baby production business altogether, they are defective breeding units, highly unreliable, and entirely too emotionally involved in what should be crop production.

Lets create a nice fetus farm where you can order the color, intellect, personality and ability configuration that is needed by the society and remove amatuerish parents and doctors from the process.

We should spend less time on saving these human bred babies and more time on creating an artifical uterus... read my book ! A. Huxley

Though I don't think that is what Shannon meant (correct me if I am wrong there Shannon), I think it is already a brave new world of sorts with parents now picking the sex of the child. Probably not long before picking the intelligence, etc.

I do think, however, that having disabilities is not the worst thing in life. There are plenty of disabled people that will tell you they are glad to be alive. The chance to live a life is a gift. Disability can look horrifying from the outside, but from the blogs of the disabled people I have read, they have a life. Lives they want to and are grateful to live.

Perhas we should be focusing on this when we can ensure that babies we resus now are not going to endure any pain in their long journey? Mayby then we can consider other things? We often moce on before we have really finished what we orignially started.

I'm doing a paper on surrogacy mother in Mexico, is interesting know how the science is developing things to live longer. My question is If a scientist develop a artificial placenta is it possible to discard the surrogacy mother in a near future?. Is it ethical?

Thank you so very much for all that you do. I could not imagine myself being in your shoes - you too would probably have a difficult time imagining yourself in ours as well. Our son, Levi, is a complete Miracle because of the ethics issues that we faced when my water broke at 23.5 weeks. We were informed that 24 weeks was the cut off due to the ethics involved according to our hospital. We praise God every day that our son (who was born exactly 16 weeks early on 10/30/07 )waited until the day he turned 24 weeks to arrive. Had he arrived a day earlier, they would not have treated him. He now shows zero signs of prematurity. My personal opinion is that we should do everything in our power - if and only if a child passes on after that point than at least we know we did all that we were capable of. Please feel free to visit his blog at blessedbledsoes.blogspot.com

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The idea of an artificial placenta has been pursued in experimental research sinceearly 1960s. The principle has not yet been successfully implemented in neonatal care regardless of the constant evolution in extracorporeal life support technology and advancements in neonatal intensive care generally. For more than 30 years, the physical size of the required equipment necessitated pump-driven circuits; however, recent advances in oxygenator technology have allowed search for the simpler and physiologically preferable idea of pumpless arteriovenous oxygenation. We expect that further miniaturization with the extracorporeal circuit allows the implementation of the idea into clinical application being an assist device.

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